Experts shared updated guidance for treating chronic lymphocytic leukemia (CLL) and small lymphocytic lymphoma (SLL) in a recent viewpoint article published in Blood Advances. Theno p consensus group, convened by the Lymphoma Research Foundation, discussed how they evaluate patients prior to treatment, which therapies they use across various settings, and how they handle unique treatment scenarios, among other considerations.

In part 1, Physician’s Weekly (PW) reported some of the pre-treatment assessments the experts shared. In addition to factors like patient preferences, organ function, and comorbidities, the experts recommended that clinicians screen for disease burden and Richter transformation:

› Hematologic function: In patients with neutropenia, anemia, or thrombocytopenia, a bone marrow biopsy helps distinguish CLL/SLL-related causes from other etiologies, such as myelodysplasia or prior treatment effects.

› CT Imaging: CT is recommended at diagnosis if lymphadenopathy or splenomegaly is present, or if clinically indicated. Notably, CT imaging is required prior to venetoclax-based therapy to assess the risk of tumor lysis syndrome (TLS), but it is not routinely used for diagnosis, surveillance, or treatment monitoring.

› TLS: TLS risk is higher with bulky disease and kidney dysfunction. TLS monitoring should follow treatment package insert protocols.

› Autoimmune Complications: Clinicians should consider guiding patients with autoimmune conditions toward regimens that include anti-CD20 monoclonal antibodies.

› Richter Transformation: Clinicians should consider Richter transformation in patients with B-symptoms, rapid/asymmetric progression, or unexplained high lactate dehydrogenase. Fludeoxyglucose positron emission or CT imaging is recommended to identify hypermetabolic areas for biopsy (preferably excisional) to confirm Richter transformation.

› Prognostic Scores: The CLL-International Prognostic Index predicts progression-free survival (PFS) and overall survival (OS) for frontline therapy and time to treatment in untreated patients. The BALL score predicts OS in patients with relapsed/refractory on BTK inhibitors, PI3Kδ inhibitors, or venetoclax, with low-risk scores predicting better responses to liso-cel. The 4-factor model is prognostic for PFS, OS, and BTK/PLCG2 mutation risk in patients receiving ibrutinib.

In part 3, PW will review the experts’ recommendations regarding molecular testing prior to treatment.